An X-ray of the right shoulder taken on August 20th, provided on a CD (I do not have the report as the doctor is on vacation), shows a calcification approximately 2-3 cm in size as determined by a general practitioner. I would like your opinion.

Treatment depends on the following factors: size, shape, location, phase, and symptoms.

Size:

  • Calcifications up to 1 cm are considered small,
  • 1-2 cm are considered large,
  • Over 2 cm are considered very large.
  • The larger the calcification, the less likely conservative treatment will be effective.

Shape:

  • Is the calcification thin and elongated, or round?
  • In the first case, if it is within the rotator cuff tendon itself, it rarely causes significant problems.

Location:

  • Front (in the subscapularis tendon): Usually causes intense but relatively short-lived symptoms that respond well to physiotherapy and exercises.
  • Middle (in the supraspinatus tendon, most common): Smaller calcifications are successfully treated conservatively. If located in the bursa, they respond poorly to classic therapy but better to shockwave therapy.
  • Back (in the infraspinatus tendon): Rare and cause fewer issues or are found incidentally during ultrasound examinations.

Phase:

  • Every calcification has three phases: formation, maintenance, and resorption.
  • In the first phase, pain is well managed with blocks.
  • During the maintenance phase, shockwave therapy may help.
  • In the resorption phase, classic physiotherapy is beneficial.

Symptoms:

  • We often see very large calcifications causing minor issues and relatively small ones causing significant pain.

All these factors guide treatment towards:

  • Medication therapy: For acute pain that is continuous and occurs at night.
  • Classic physiotherapy, manual therapy, exercises: For subacute pain, not occurring at night, mainly during specific movements, in the second and third phases of the calcification’s life, and not highly irritable.
  • Shockwave therapy: For calcifications that periodically cause flare-ups, with pain never fully subsiding, and when other treatments have failed.
  • Barbotage (“washing out the calcification”) and surgical therapy: When the calcification is too large or after unsuccessful conservative treatment.

All these rules have many exceptions.

Writes:

Dean Mistura | Physiotherapist, founder and director of Scipion Polyclinic